Healthcare Provider Details

I. General information

NPI: 1083895965
Provider Name (Legal Business Name): KELLEY SMODIC CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 WOODWARD DR SUITE 4
GREENSBURG PA
15601-7228
US

IV. Provider business mailing address

1117 WOODWARD DR SUITE 4
GREENSBURG PA
15601-7228
US

V. Phone/Fax

Practice location:
  • Phone: 724-834-0432
  • Fax: 888-972-1731
Mailing address:
  • Phone: 724-834-0432
  • Fax: 888-972-1731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberSP008361
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP008361
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSP008361
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberSP008361
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: